Department of Veterans Affairs

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. The OIG inspected four randomly selected vet centers throughout Pacific district 5 zone 3: Phoenix and West Valley, Arizona; Antelope...

The OIG evaluated allegations related to the care of a patient who died by suicide six days after a mental health appointment at the VA Tuscaloosa Healthcare System (facility). Concerns regarding appointment scheduling, supervision of a posttraumatic stress disorder (PTSD) clinic social worker...

VA’s Veterans Transportation Program offers travel solutions for veterans to get to and from VA healthcare facilities at little or no cost to veterans. One travel option is transportation by wheelchair van. VA’s Health Administration Service is responsible for administering the contracts that...

The VA Office of Inspector General (OIG) conducted this audit to determine whether VA and its contractor had sufficient controls to prevent, respond to, and mitigate the impact of major performance incidents affecting the electronic health record (EHR) system.In May 2018, VA awarded a 10-year...

The VA Office of Inspector General (OIG) assessed VA’s compliance with mandated reporting of staffing and vacancy data on its public website and its clarity in related explanations. The MISSION Act of 2018 requires VA to publicly release this information each quarter to promote transparency in...

In March 2021, the Veterans Benefits Administration (VBA) began transitioning to a Digital GI Bill platform designed to improve education benefits delivery. The original plan called for implementing the new platform through a contractor for 10 years at a projected cost of $453 million. The VA Office...

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).This inspection evaluates four review areas within Continental District 4 including leadership stability...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and...

The Office of Inspector General (OIG) evaluated concerns related to Veterans Integrated Service Network (VISN) 10 staff’s care and treatment coordination for a patient who died. The OIG reviewed the sufficiency of Veterans Health Administration (VHA) leaders’ actions prior to and following...

The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.The OIG...